Advances In The Treatment Of Intractable Bell’s Palsy
Bell’s palsy is the most common cause of one side facial paralysis. It is a result of inflammation of a brainstem nerve termed cranial nerve VII (facial nerve) as it exists the skull via an opening called the stylomastoid foramen. It results in an inability to control the muscles on the affected side of the face. Bell’s palsy is self-limiting and function starts to be regained within 3 weeks in most cases. However in some cases the restoration of function is not attained within the first 3 weeks and sequelae may ensue. These cases fall into what is termed intractable Bell’s palsy. Complications can include tinnitus (ringing in the ears), facial synkinesis (uncoordinated movements of the face), facial spasm, facial contracture, facial paralysis, and aguesia (loss of taste).
Bell’s palsy is often referred to as a mono-neuropathy, meaning involving one nerve. However quite often there is a myriad of neurological symptoms which cannot be explained by the dysfunction of the facial nerve solely. Headache, neck pain, memory problems, balance problems, ipsilateral (same side) limb dysesthesias, same side limb weakness, and clumsiness can accompany the disorder. Therefore more prevailing mechanisms for the disorder involve functional deficits in neurons in and around the brainstem.
Conservative, non-surgical treatment options for intractable Bell’s palsy focuses on reducing inflammation to the facial nerve and stabilizing the neurological activity within the brainstem. Photobiomodulation (Class IV laser therapy) has been shown clinically to have very promising outcomes. This therapeutic intervention is non-invasive and utilizes specific wavelength of light (red and near- infrared) to achieve healing effects. It draws water, oxygen, and nutrients to the damaged area to accelerate tissue repair. Class IV laser therapy also has an effect at the cell level increasing metabolic activity within the cell thus improving the transport of nutrients across the cell membrane.
In reference to the brainstem instability and functional deficit, a full neurological battery of tests must be completed to triangulate the lesion and thus allow for more accurate treatment. Exam protocols include a videonystagmography (VNG), computerized assessments of postural systems (CAPS), and thorough neurological and orthopedic bedside evaluation. Subsequently, targeted rehabilitative therapies are performed aimed at creating adaptive plasticity (proper neuron activity) in the region and thus stability. Therapies might include oculomotor exercises (eye movements), specific facial exercises with electrical stimulation of the trigeminal distribution of the face while looking at a mirror, Dynavision D2 (64 LED computerized timing board), and facial remapping exercises on the side of the paralysis to name a few. Conservative mechanisms should always be attempted before surgical intervention.
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